CommercialPrior AuthHigh impact
Daunorubicin-Cytarabine Liposome (Vyxeos) (CPB 0921, reviewed 2026-06-12)
Aetna·Oncology, Hematology, Internal Medicine·Medical Policy
Effective date
Jun 12, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its clinical policy for Vyxeos (daunorubicin-cytarabine liposome) effective immediately, establishing specific medical necessity criteria for initial approval, continuation of therapy, and dosage/administration guidelines for AML, MDS, and CMML treatment. Billing teams must now enforce prior authorization requirements based on diagnosis type, therapy phase (induction/consolidation/re-induction), and cycle limits to ensure claim approval.
Action Required
Effective immediately (policy reviewed 2026-06-12): Billing team must implement prior authorization requirements for all Vyxeos claims before submission. (1) Update billing software to require prior auth for HCPCS code J9153 when billed with specific ICD-10 codes (C92.00-C92.62, C93.10-C93.12, D46.0-D46.Z). (2) Verify diagnosis codes match approved indications: t-AML (other than CBF-AML), AML from MDS/CMML, AML-MRC, or poor-risk AML with TP53/del(17p). (3) Enforce cycle limits in prior auth: maximum 2 induction cycles (including re-induction) and maximum 2 consolidation cycles. (4) Require documentation of no unacceptable toxicity after first cycle for continuation approvals. (5) Update encounter forms and EMR templates to capture therapy phase (induction/consolidation/re-induction) and cycle number at point of service. (6) Reject or reroute claims for non-approved indications (e.g., CBF-AML, APL, other diagnoses) as experimental/investigational. (7) Train billing staff that Vyxeos dosing differs by therapy phase (44/100 mg/m² induction vs. 29/65 mg/m² consolidation) and requires accurate documentation. Consequences: Claims submitted without prior authorization or exceeding cycle limits will be denied; claims for non-covered diagnoses will be denied as investigational.